Preventable hospital admissions and readmissions are indicators of health system fragmentation and are associated with suboptimal patient outcomes and avoidable costs of care. Readmissions often result from leaving discharged patients to their own devices, unable to follow instructions they didn't understand, and not taking medications or getting the necessary follow-up care. Effective care coordination and transitions from hospital to home can prevent many of the poor outcomes that give rise to hospital readmissions and reduce the economic costs of healthcare. The proposed initiative will design and test an innovative, systematic approach to managing hospital discharges of Medicaid patients who are served by an Accountable Care Organization (ACO). Due to the prevalence, hospitalization rates and associated costs of type 2 diabetes and comorbidities, we will tailor the intervention to that population. Care Coordinators employed by the ACO will be trained to use a transition care planning toolkit with hospitalized patients and their care teams. Components of this approach include managing medications following discharge, coordinating outpatient care supports, clarifying how the patient can best use his or her care providers, addressing special needs of the patient to succeed at home following discharge, etc. The long term goal will be to test the efficacy of this intervention approach to reduce 30-day rehospitalizations. During this Phase I study we will: (1) Design a toolkit (materials and processes) to assist patients and their ACO Care Coordinators plan for a maintaining their health following discharge from the hospital. [(2) Train ACO Care Coordinators (N= 8) in the use of these tools and processes and have these Care Coordinators utilize the tools and processes with Medicaid beneficiaries (N=48).] (3) Test the initial design of tools and processes for acceptability among patients and the Care Coordinators using semi-structured interviews and focus groups. Feedback from these interviews and focus groups will be used to refine the program design. The proposed research is intended to develop intervention materials tailored to the unique needs of targeted patients receiving care support within the context of an ACO delivery structure. These materials will be structured to be marketed as a complete integrated product. Because of the prevalence of type 2 diabetes complications, associated hospitalizations are high. If acceptability metrics are achieved, this approach could provide a base for future efficacy testing and meet the needs of Medicaid programs in many States.